HomeMy WebLinkAbout2025-00071212 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
I0110 1111,01111111 �01000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV 5340*
u, 1 U21 3 4 1 u, 8 U2 1 u, 1 u2 1 u, 1 U2 1 1 10 u, 3 U2 3 *P0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 4
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00071212 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mN STATE ST El In04:12
® ❑ RELATED ®Y 0 N 11 01 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W W CH ICAGO ST COUNTY PROPERTY ❑ ® N mo
® DOORING Ely #OF MOTOR El SLOW 2 fA
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NIA/ ❑NCv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
T TOWED U1 Q
Ford Exlorer 00-NONE •
NAME(LAST,FIRST,M) Chavez Nava. Norma mo yr 2004 p 13-UNDER CARRIAGE 1t,) 12! 0 2 FIRE DUE TO CRASH ❑❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 2 DISTRACTED 0 0 U2 0 m
F 2 4 15-OTHER
❑Y ®N
SYSTEM
❑UNK VEH. 0 AT CRASH D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 �i 4 COM VEH 0 j$J 1 O
F. FIRST CONTACT 1 7 ;—_;__5 *IIYes.See Sidebar Ut
Z Crystal Lake IL 60014 0 1 0 EW82454 IL 2026
TELEPHONE
IL D 0 1 FMZU73E84UC00291 State Farm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 2812850SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused 0 Y ® N 2 XI
Eg DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑
Yr
/2 0 0 3 Dodge Ram 1500(pickup) 2022 00-NONE 'o,� t2 c,�2 DUE TO CRASH ® U2 2 C
o 13-UNDER CARRIAGEFIRE 0
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistractlon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'ij- 6 il;, 4 COM VEH ❑ ® u1 CO
C
FIRST CONTACT 8 O7 ;J__,l�_5 •(ryes,See Sidebar
ELGIN IL 60123 0 1 0 4164049B IL 2026 I Si)0
IL D 0 3C63RRPL5NG357417 Selective Insurance Co ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same S2670210 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOei (SEX) {SAFT) (AIR) (INJI 1(EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 6 07 /
U2 2 Z
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID
u 1 ® 11 1 11 /01 l2025 04 13 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0
2 20 28 / / ❑PM ❑Construction *
1 4
Z3 ❑ j i CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
o ® 11 1 ARREST NAME Chavez Nava. Norma 11-708 S1519-000419 / ! El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
El AM
r 2 El ARREST NAME 1 1/01 /2025 04 50 ®PM El Unknown work zone type U1 3O
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - 0 AM Workers present? ❑N 30
151 9-Bae2 a.Guadalupe 601 11 /01 /2025 ❑PM ®N U2
REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS!
A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE
even if units have been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` -'- -' r INDICATE NORTH combination):or 5311
Haar:atom ; BY ARROW 2 Is used or designed to transport more than 15 passengers including the driverC_ } (example:shuttle or charter bus):orX
3. Is designed to car 15 or fewer ssen ers and o rated a contract carrier O
- } } } transporting employees In the course�of their empbym�ent(example:employee � X
transporter-usually a van type vehicle or passenger car):or wL -----}----; r 4 - } } } C
4. Is used or designated to transport between 9 and 15 passen rs,including the driver,for direct compensation(example:large van used for specific purpose):ortoL L____a..... i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires mW?Chicego?8r - , . , .
l pWcartling(example:placards will be displayed on the vehicle). XI
M
————— CARRIER NAME Z
10r°, ADDRESS 0
I I C
w n
p . . . . _
CITY/STATE/ZIP 0
I I MOTOR CARR.ID 0 Interstate 0 Intrastate
0
1 I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --• - USDOT NO. ILCC NO. m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Beige White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE